Monday, October 26, 2009

Electronic medical records not seen as a cure-all

In a health-care debate characterized by partisan bickering, most lawmakers agree on one thing: American medicine needs to go digital.

When President Obama designated $19.5 billion to expand the use of electronic medical records, former House speaker Newt Gingrich (R-Ga.) said it was one of only "two good things" in February's stimulus package.

But such bipartisan enthusiasm has obscured questions about the effectiveness of health information technology products, critics say. Interviews with more than two dozen doctors, academics, patients and computer programmers suggest that computer systems can increase errors, add hours to doctors' workloads and compromise patient care.

"Health IT can be beneficial, but many current systems are clunky, counterintuitive and in some cases dangerous," said Ross Koppel, a sociologist at the University of Pennsylvania School of Medicine who published a key study on electronic medical records in 2005.

Under the stimulus program, hospitals and physicians can claim millions of dollars for IT purchases, and will be penalized if they do not go digital by 2015. Obama has said the changes will save billions and will minimize medication errors.

But health IT's effectiveness is unclear. Researchers at the University of Minnesota found in March that electronic records prevented only two infections a year. A 2005 report in the journal Pediatrics found that deaths at the children's hospital at the University of Pittsburgh Medical Center more than doubled in the five months after a computerized order-entry system went online. UPMC said the study had not found that technology caused the rise in mortality and maintained that medication errors were down 60 percent since computers were introduced in 2002.

Others studies have concluded that health IT saves time and reduces errors. It has been used successfully in organizations such as the Department of Veterans Affairs and Kaiser Permanente.

Documenting the flaws

However, the Senate Finance Committee has amassed a thick file of testimony alleging serious computer flaws from doctors, patients and engineers unhappy with current systems.

On Oct. 16, the panel wrote to 10 major sellers of electronic record systems, demanding to know, for example, what steps they had taken to safeguard patients. "Every accountability measure ought to be used to track the stimulus money invested in health information technology," said Sen. Charles E. Grassley (Iowa), the panel's ranking Republican.

Anonymous reports sent to the Joint Commission, the body charged with certifying 17,000 health-care organizations; Grassley's staff; and the Food and Drug Administration disclose problems, including:

-- Faulty software that miscalculated intracranial pressures and mixed up kilograms and pounds.

-- A computer system that systematically gave adult doses of medications to children.

-- An IT program designed to warn physicians about wrong dosages that was disconnected when the vendor updated the system, leading to incorrect dosing.

-- A software bug that misdiagnosed five people with herpes.

David Blumenthal, the head of health technology at the Department of Health and Human Services, acknowledged that the systems had flaws. "But the critical question is whether, on balance, care is better than before," he said. "I think the answer is yes."

Over the next two months, Blumenthal will finalize the definition of "meaningful use," the standard that hospitals and physicians will have to reach before qualifying for health IT stimulus funds. He would not say whether applicants would have to submit adverse-event reports, a safety net that many doctors and academics have called for but that vendors have resisted.

"If you look at other high-risk industries, like drug regulation or aviation, there's a requirement to report problems," said David C. Classen, an associate professor of medicine at the University of Utah who recently completed a study on health IT installations.

Today, barely 8 percent of hospitals have even a basic electronic medical system. Only 17 percent of physicians use electronic records, and many of those are uninstalling them, including 20 percent of physician groups in Arizona, according to a June survey by HealthLeaders-InterStudy.

Outside the United States, countries further along the digital curve have experienced major problems with American-made health IT systems.

In Britain, a $20 billion program to digitalize medicine across the National Health Service is five years behind schedule and heavily over budget. A British parliamentary committee in January criticized the vendor, Cerner, as "not providing value for money."

Sarah Bond, a Cerner spokeswoman, said patient safety had improved and errors had dropped at U.S. hospitals that used Cerner products.

Cerner's stock price has risen 122 percent since February. Shares in Allscripts, another major health IT player whose chief executive, Glen E. Tullman, served on Obama's campaign finance committee, rose by 126 percent over the same period.

But rising share prices have not always translated into better care.

"It's been a complete nightmare," said Steve Chabala, an emergency room physician at St. Mary Mercy Hospital in Livonia, Mich., which switched to electronic records three years ago. "I can't see my patients because I'm at a screen entering data."

Last year, his department found that physicians spent nearly five of every 10 hours on a computer, he said. "I sit down and log on to a computer 60 times every shift. Physician productivity and satisfaction have fallen off a cliff."

Other doctors spoke of cluttered screens, unresponsive vendors and illogical displays. "It's a huge safety issue," said Christine Sinsky, an internist in Dubuque, Iowa, whose practice implemented electronic records six years ago. "I can't tell from the medical display whether a patient is receiving 4mg or 8mg of a certain drug. It took us two years to get a back-button on our [Electronic Health Record] browser."

She emphasized that electronic records have improved her practice. "We wouldn't want to go back," she said. "But EHRs are still in need of significant improvement."

More than one in five hospital medication errors reported last year -- 27,969 out of 133,662 -- were caused at least partly by computers, according to data submitted by 379 hospitals to Quantros Inc., a health-care information company. Paper-based errors caused 10,954 errors, the data showed.

Tracking the mishaps

Legal experts say it is impossible to know how often health IT mishaps occur. Electronic medical records are not classified as medical devices, so hospitals are not required to report problems. Many health IT contracts do not allow hospitals to discuss computer flaws, say Koppel and Sharona Hoffman, a professor of law and bioethics at Case Western Reserve University in Cleveland.

"Doctors who report problems can lose their jobs," Hoffman said. "Hospitals don't have any incentive to do so and may be in breach of contract if they do."

For one senior internist at a major hospital, who requested anonymity because he said he would lose his job if he went public, a 2006 installation provoked mayhem. "The system crashed soon after it went online," he said. "I walked in to find no records on any patients. It was like being on the moon without oxygen."

While orange-shirted vendor employees "ran around with no idea how to work their own equipment," the internist said, doctors struggled to keep chronically ill patients alive. "I didn't go through all my training to have my ability to take care of patients destroyed by devices that are an impediment to medical care."